Cutaneous melanoma of the head and neck: advances in evaluation and treatment

Methods of Sentinel Lymph Node Identification in Auricular Melanoma

Sentinel lymph node biopsy is used to evaluate for micrometastasis in auricular melanoma. However, lymphatic drainage patterns of the ear are not well defined and predicting the location of sentinel nodes can be difficult. The goal of this study was to define the lymphatic drainage patterns of the ear and to compare multiple modalities of sentinel node identification.

METHODS

A retrospective review of a prospectively maintained database evaluated 80 patients with auricular melanoma who underwent sentinel lymph node biopsy by comparing preoperative imaging with intraoperative identification of sentinel nodes. Patients were placed into two cohorts, based on the modality of preoperative imaging: (1) planar lymphoscintigraphy only (n = 63) and (2) single-photon emission computerized tomography combined with computerized tomography (SPECT-CT) only (n = 17). Sites of preoperative mapping and sites of intraoperative identification were recorded as parotid/preauricular, mastoid/postauricular, and/or cervical.

RESULTS

In patients that underwent planar lymphoscintigraphy preoperatively (n = 63), significantly more sentinel nodes were identified intraoperatively than were mapped preoperatively in both the parotid/preauricular (P = 0.0017) and mastoid/postauricular (P = 0.0047) regions. Thirty-two nodes were identified intraoperatively that were not mapped preoperatively in the planar lymphoscintigraphy group (n = 63), two of which were positive for micrometastatic disease. In contrast, there were no discrepancies between preoperative mapping and intraoperative identification of sentinel nodes in the SPECT-CT group (n = 17).

CONCLUSIONS

SPECT-CT is more accurate than planar lymphoscintigraphy for the preoperative identification of draining sentinel lymph nodes in auricular melanoma. If SPECT-CT is not available, planar lymphoscintigraphy can also be used safely, but careful intraoperative evaluation, even in basins not mapped by lymphoscintigraphy, must be performed to avoid missed sentinel nodes.

Recurrence Rates Over 20 Years in the Treatment of Malignant Melanoma: Immediate Versus Delayed Reconstruction

Wide local excision (WLE) with a safety margin is the standard of treatment for primary head and neck cutaneous malignant melanoma (HNCMM). Studies have demonstrated inconsistency in recurrence rates following immediate versus delayed reconstruction. The objectives of this study were to assess and compare recurrence rates after WLE of HNCMM followed by immediate or delayed reconstruction in determining recurrence-free survival estimates.

Malignant Melanoma: Beyond the Basics

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Discuss the initial management of cutaneous malignant melanoma with regard to diagnostic biopsy and currently accepted resection margins. 2. Be familiar with the management options for melanoma in specific situations such as subungual melanoma, auricular melanoma, and melanoma in the pregnant patient. 3. Discuss the differentiating characteristics of desmoplastic melanoma and its treatment options. 4. List the indications for sentinel lymph node biopsy and be aware of the ongoing trials and current literature. 5. Discuss the medical therapies available to patients with metastatic melanoma.

SUMMARY

Management of the melanoma patient is a complex and evolving subject. Plastic surgeons should be aware of the recent changes in the field. Excisional biopsy remains the gold standard for diagnosis, although there is no evidence that use of other biopsy types alters survival or recurrence. Wide local excisions should be carried out with margins as recommended by National Comprehensive Cancer Network guidelines according to lesion Breslow depth, with sentinel lymph node biopsy being offered to all medically suitable candidates with intermediate thickness melanomas (1.0 to 4.0 mm), and with sentinel lymph node biopsy being considered for high-risk lesions (ulceration and/or high mitotic figures) with melanomas of 0.75 to 1.0 mm. Melanomas diagnosed during pregnancy can be treated with preoperative lymphoscintigraphy and wide local excision under local anesthesia, with sentinel lymph node biopsy under general anesthesia delayed until after delivery. Management of desmoplastic melanoma is currently controversial with regard to the indications for sentinel lymph node biopsy and the efficacy of postoperative radiation therapy. Subungual and auricular melanoma have evolved from being treated by amputation of the involved appendage to less radical procedures-ear reconstruction is now attempted in the absence of gross invasion into the perichondrium, and subungual melanomas may be treated with wide local excision down to and including the periosteum, with immediate full-thickness skin grafting over bone. Although surgical treatment remains the current gold standard, recent advances in immunotherapy and targeted molecular therapy for metastatic melanoma show great promise for the development of medical therapies for melanoma.

Role of selective sentinel lymph node dissection in head and neck melanoma

Selective sentinel lymph node dissection (SLND) plays an important role in the staging of the regional nodal basins for head and neck (H&N) melanoma. Preoperative lymphoscintigraphy is mandatory to identify the regional nodal basin(s) accurately for a newly diagnosed H&N primary melanoma of at least 1mm or greater. A wide local excision should be delayed if SLN mapping is indicated, to minimize watershed effect and maximize accuracy in identifying the "true" SLN because of the complex lymphatic network in the H&N region. An experienced multidisciplinary team is required for optimal identification of H&N SLNs. In general, selective SLND can replace ELND to minimize the complications of a neck dissection. Completion lymph node dissection is only indicated when the SLN is positive. A nerve stimulator should be used during selective SLND in the parotid and posterior triangle to minimize the injury to the facial and spinal accessory nerve.

Tumor location predicts survival in cutaneous head and neck melanoma

BACKGROUND

Prior studies documented poorer outcomes in patients with cutaneous head and neck melanoma (CHNM) relative to those with melanoma at other sites. We evaluated survival differences attributable to tumor location in patients with CHNM.

METHODS

We queried the Surveillance, Epidemiology, and End Results (SEER) database for patients undergoing surgery for CHNM from 1988 to 2006, excluding patients without biopsy-proven diagnoses, those diagnosed at autopsy, and patients with distant metastases. Using the Kaplan-Meier method, we assessed patient, tumor, and treatment-specific factors on overall survival (OS) and melanoma specific survival (MSS). Cox proportional hazards models assessed the role of tumor location (ear, eyelid, face, lip, scalp/neck) on OS and MSS, while controlling for patient age, gender, race, tumor thickness, tumor ulceration, lymph node status, histologic subtype, type of surgery, and use of radiation. Risks of overall and melanoma-specific mortality were reported as hazard ratios (HR) with 95% confidence intervals (CI).

RESULTS

Among 27,097 patients, 10-y rates of OS and MSS were 56.1% and 84.7%, respectively. On multivariate analysis, scalp/neck primary site was associated with an increased risk of overall (HR 1.20, CI 1.14-1.26; P < 0.001) and melanoma-specific mortality (HR 1.64, CI 1.49-1.80, P < 0.001) relative to melanomas of the face. Tumors of the lip had poorer MSS (HR 1.55; CI 1.05-2.28, P = 0.03) but not OS (HR 1.03, CI 0.80-1.34; P = 0.80).

CONCLUSIONS

Patients with melanomas of the scalp/neck have poorer OS and MSS and those with lip melanomas have poorer MSS. These anatomic areas should not be overlooked when performing skin examinations.

Optimal management and challenges in treatment of upper facial melanoma

This study's purpose was to evaluate clinical and surgical outcomes in patients with upper facial melanoma. A sentinel lymph node (SLN) biopsy database review identified 43 patients receiving a diagnosis of upper facial melanoma between February 1997 and April 2005 at Mayo Clinic Arizona in Scottsdale. Patients underwent wide local excision (n = 40) or Mohs excision (n = 3) and SLN biopsy. Nine patients (21%) had positive margins requiring reexcision. SLN mapping identified the SLN in 39 patients (91%) and drainage to bilateral lymph node basins in 8 (21%). The SLN was positive for melanoma in 2 patients (5%). Recurrence in 33 patients with more than 1 year of follow-up (local in 5 [15%] and regional in 1 [3%]) was treated with salvage surgery; 1 patient developed metastatic disease. Two patients (5%) died, one of an unknown cause and the other of metastatic melanoma. We concluded that oncologic surgery can result in good local disease control in patients with upper facial melanoma.

Mise au point sur la prise en charge chirurgicale du mélanome malin cutané. Revue de la littérature

Nowadays managing a cutaneous malignant melanoma can concern different kind of physicians: dermatologists, general or plastic surgeons The primary surgical procedure is a major step of the treatment. Biopsy must be total to properly determine the thickness of the tumor in case of malignancy. Wide local excision of the scar is often necessary to decrease the local and general recurrence rates. Wide local excision must be performed conforming to its own surgical rules. Managing tumor located on the face or limb extremities is a matter of plastic surgery. Sentinel node biopsy has succeeded to elective lymph node dissection. This procedure allows research of lymphatic spreading of the disease. Practice of sentinel node biopsy must be achieved in a protocolar way. Topography of the lesion can modified achievement and results of this procedure. Prognosis benefit of sentinel biopsy is now clear. Elective lymph node dissection is only performed in case of invaded sentinel node or clinically invaded lymph nodes. Local or locoregional recurrences mainly respond to surgical treatment using wide excision. However, alternative solutions are being evaluated (isolated limb perfusion).

Intraparotid Sentinel Lymph Node Biopsy for Head and Neck Melanoma

OBJECTIVE

The objective of this retrospective clinical review was to assess the safety and accuracy of intraparotid sentinel node biopsy in patients with melanoma.

SETTING

This study was conducted at a tertiary referral center.

PATIENTS

Twenty-eight patients with cutaneous melanoma of the head and neck undergoing sentinel lymph node (SLN) biopsy in which the radionuclide localized to the parotid gland on preoperative lymphoscintigraphy were studied.

METHODS

All patients underwent wide local excision of the tumor and intraparotid sentinel node biopsy using intraoperative gamma probe localization.

RESULTS

There were 25 men and 3 women ranging in age from 34 to 81 years. The primary site was on the auricle in 14 patients: temple, 4; forehead, 5; cheek, 3; and on the neck in 2 patients, respectively. The mean Breslow thickness was 2.3 mm (range, 0.9-7.0 mm). In 27 of 28 patients, an intraparotid SLN was identified. In one patient, final pathology did not reveal lymphoid tissue despite a high count in the parotid tissue excised. Median number of SLN per patient was two. Six patients had microscopic metastases in the SLN. In two of these patients, additional microscopic lymph node metastases were found in the neck after subsequent formal lymphadenectomy. The pathologic staging for the group (n = 14) was: stage 1B, 4; 2A, 4; stage 2B, 3; and stage 3B, 3 patients, respectively. All patients are alive and without evidence of disease (mean follow up, 31 months). There were no surgical complications, specifically no patient experienced temporary or permanent facial paralysis.

CONCLUSION

Intraparotid SLN biopsy for staging cutaneous head and neck melanoma is a reliable, accurate, and safe procedure.

Lymphoscintigraphic drainage patterns of the auricle in healthy subjects

BACKGROUND

In lymphoscintigraphies of the head and neck, multiple injections around a tumor result in variable drainage to multiple nodal basins. We undertook this study in healthy subjects to test whether single injections at specified points in the auricle display single predictable pathways and predict visualization of parotid sentinel lymph nodes (SLNs).

METHODS

Twenty-five healthy subjects were classified according to their injection points in the auricle. Each was injected bilaterally with 99mTc nanocolloid. Parotid and extraparotid lymph nodes were topographically differentiated. The procedure was repeated 1 week later.

RESULTS

Lymphoscintigraphy was reproducible. Each injection revealed a single SLN. Injection site predicted parotid SLN visualization. Two lymphatic territories with parotid or extraparotid drainage were identified.

CONCLUSIONS

Lymphatic territories in the auricle coincide with the vascular territories and branchial origins. Our findings contradict the notion that lymphatic drainage of the head and neck is unpredictable and variably involves multiple nodal basins.

Changing surgical therapy for melanoma of the external ear

BACKGROUND

The purpose of this study was to evaluate the prognostic variables and clinical ramifications of melanoma of the ear.

METHODS

A retrospective chart review of patients treated since 1985 at the Mayo Clinic in Scottsdale, AZ, and Rochester, MN, identified 78 patients with complete follow-up.

RESULTS

Of these 78 patients, 68 (87%) were men; the mean age was 64 years (range, 23-87 years). Melanoma thickness averaged 1.7 mm (range,.2-7.0 mm). Treatment of the primary melanoma included wedge resection (59%), Mohs resection (14%), partial amputation (11%), skin and subcutaneous resection with perichondrium preservation (9%), and total amputation (7%). Nineteen patients underwent an elective lymph node dissection, and lymph node metastases were found in seven (37%). Two patients presented with clinically positive lymph nodes. Sentinel lymph node biopsy was performed in 10 patients. After a mean follow-up of 55.7 months, 10 patients (13%) had local recurrence, 9 patients (12%) had regional recurrence, and systemic metastases had developed in 17 patients (22%). Tumor thickness, lymph node metastases, and local recurrence significantly affected systemic recurrence.

CONCLUSIONS

The treatment of malignant melanoma of the external ear should follow current standard guidelines, which require wide local excision with negative margins. Sentinel lymph node biopsy can be used to identify patients with lymph node metastases who are at high risk of recurrence.

Prevalence of additional positive lymph nodes in complete lymphadenectomy specimens after positive sentinel lymphadenectomy findings for early-stage melanoma of the head and neck

In this study, the prevalence of additional positive lymph nodes in subsequent complete lymphadenectomy specimens for patients with early-stage melanoma of the head and neck, after positive sentinel lymphadenectomy results, was retrospectively analyzed. In the past 5 years at the authors' institution, 23 consecutive patients with clinical stage I or stage II melanoma of the head and neck underwent complete lymphadenectomies after positive sentinel lymph node biopsies and wide local excisions of the primary lesions. Sentinel lymph nodes were identified with intraoperative lymphatic mapping techniques (radiolymphoscintigraphy and vital blue dye injection) and were examined with routine histological methods and immunohistochemical staining for S-100. All lymph nodes harvested in complete lymphadenectomies were examined with routine histological techniques. Twenty-one patients (91.3 percent) demonstrated no additional positive lymph nodes in subsequent complete lymphadenectomy specimens; two patients (8.7 percent) each demonstrated one additional positive lymph node in the complete lymphadenectomy specimens. Both patients had ulcerated primary lesions more than 5 mm in depth. No patient developed a regional nodal recurrence during a mean follow-up period of 23.7 months (range, 2 to 56 months). The low prevalence of additional positive lymph nodes in complete lymphadenectomy specimens suggests that when microscopic metastases exist in the regional nodal basin, most of the time they are confined to the sentinel lymph nodes of patients with early-stage melanoma of the head and neck. Nevertheless, the question of whether subsequent complete lymphadenectomy is still necessary for this subgroup of patients warrants further study.